Purpose
To establish standardized procedures for discussing, documenting, and maintaining advanced directives in compliance with state laws and medical best practices.
Policy Statement
This practice shall respect and implement patients' wishes regarding their medical care as expressed through properly executed advanced directives.
Procedures
1. Initial Patient Contact
- Ask all new patients aged 18 and older about existing advanced directives
- Document presence or absence of advanced directives in EMR
- Provide information packet about advanced directives to interested patients
2. Documentation Requirements
- Scan all advanced directives into patient's EMR
- Flag chart with advanced directive alert
- Update advanced directive status at minimum annually
3. Staff Responsibilities
Front Desk Staff
- Inquire about advanced directives during registration
- Maintain supply of advanced directive forms and information packets
- Forward new documents to clinical staff
Clinical Staff
- Review advanced directives for completeness
- Assist with witness requirements when appropriate
- Update EMR documentation
Providers
- Discuss advanced directives during annual wellness visits
- Document discussions in patient record
- Provide medical guidance as requested
4. Storage and Accessibility
- Maintain advanced directives in designated EMR section
- Ensure 24/7 accessibility to on-call providers
- Keep backup copies in secure physical location
Review and Updates
- Annual policy review required
- Updates as needed for regulatory compliance
- Staff training minimum annually
Legal References
- State Healthcare Decisions Act
- Federal Patient Self-Determination Act
- HIPAA Privacy Rule requirements
Forms
- Advanced Directive Status Form
- Living Will Template
- Healthcare Power of Attorney Form
- Advanced Directive Information Packet